A Paperless NHS

19th February 2013

Given the usual scant regard to the commonly accepted meaning of words that seems to be the norm in the NHS – “Paperless” is something that we now have in the majority of general practices and that many have had for some years and I’m really enthusiastic about the desire from the centre to drag the rest of the NHS into the Digital Age, but am really concerned that the initiative is being driven by a leadership who are, to be frank, clueless.

Firstly, the focus is wrong – Creating electronic records and/or removing paper, desirable as these may be, should not be the objective. The objective should to use technology to support and coordinate the processes of care so that the patient sees a integrated service that delivers greater convenience and quality.

This inevitably means more digital services, and will result in the creation of electronic records and the removal of paper from many processes, but in a way where these changes support process improvement. This is what happened in general practice – Processes were digitised one-by-one and the data needed to support this digitisation was stored in electronic records. Over time these records became comprehensive and GP practices have become “paperlite” this approach gave quick wins and avoided the risk of suddenly trying to go to fully electronic records. See Lessons from GP Computing

Secondly, we don’t have the infrastructure. Already nurses and junior doctors fight over ward terminals and the COWS (Computers on Wheels) for access to IT systems and when they finally rest a keyboard from colleagues typically find themselves using obsolete hardware, operating systems and browsers accessing poorly integrated multiple systems over inadequate networks. We need to address the infrastructure issues before we can go paperless (or lite). Every health and care professional needs their own device connected with ubiquitous LAN (WiFi) and WAN(3/4G) across the whole NHS estate and out into the community for those. A paperless NHS without the infrastructure to support it will be worse than the current paper based system.

I’m all for putting pressure on NHS Trust to embrace a digital future and have some sympathy with the approach attributed to Richard Nixon: “When you have them by the short and curlies their hearts and minds will follow”. However, to secure the benefits that I believe are possible from the digitisation of the NHS we do have to win the hearts and minds of frontline staff and I don’t think this will be achieved by exhortations to do the impossible which will end up with ill-considered and poorly implement EPR systems running on wholly inadequate infrastructure damaging morale and undermining patient care.

Creating a truly digital NHS requires careful design involving the public, patients, health and care professionals and digital engineers working together to create digital services to deliver truly holistic care. It requires infrastructure that is fit for purpose and needs the support of a health IT ecosystem that ensures all of the components play nicely together.

I’m a firm believer that it is only by using information and information systems in innovative ways, both to support the way we directly deliver services and through analytics to effectively target and evaluate what we do, that we can hope to meet the challenges that the NHS and healthcare systems across the globe face. Headline political targets like “a Paperless NHS” have their place in stimulating debate, but unless they are followed by meaningful action from those who have sound insight in to how digitisation might transform the way we deliver care and involve the public and patients in the process are little more than an distraction.

The Commissioning Board should focus on the Commissioning of care (both directly and through CCGs) and making sure that personal and organisational incentives for all the actors in the system are aligned with the imperative to deliver better quality more convenient services for less. They also need to ensure that the information flows required to support individual care and monitor the performance of the system as a whole are available by making these the basis on which providers are paid for their services. I can’t see how providers can achieve the transformation required without embracing IT, widespread digitisation and social media, but hold them to account for their outputs, not how they achieve them. By setting ill-consider targets about a paperless NHS and EPRs the Commissioning Board is just giving providers excuses to fail at their core task.